Failure to Document Ongoing Assessment of Sacral Skin Condition
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy requiring evaluation and documentation of identified skin changes in the weekly skin check section of the electronic medical record. The facility’s Wound Prevention, Skin Observation policy stated that nurses must evaluate and document identified changes weekly. Resident #1, admitted after right knee surgery with a history of Vancomycin-induced acute kidney injury, atrial fibrillation, and hypertension, had a documented Stage I pressure ulcer or injury on the admission MDS and nursing notes indicating sacral redness/rashes present on admission. After two initial nursing progress notes describing the sacral redness/rashes with no signs of infection, there were no further nursing progress notes addressing this sacral skin condition, despite ongoing daily skin assessments that focused on the right knee surgical site. Interviews with staff revealed inconsistent understanding of responsibility for monitoring and documenting the sacral area. A CNA reported that she performs ongoing skin checks during daily care and reports changes to nurses, and an RN stated that she performs head-to-toe assessments on admission, documents findings, and notifies the physician. The RN also stated that weekly skin assessments were performed for the resident’s sacral redness but acknowledged she did not monitor or measure the area after admission, believing the wound care nurse was responsible. The wound care nurse reported seeing the sacral redness on admission, with a cream ordered and applied and a turning schedule in place, but stated she did not monitor the sacral area and only monitored and documented the right knee surgical site, assuming the staff nurses were monitoring and documenting the sacral redness/rashes. The resident’s care plan required weekly monitoring, measuring, and documentation of the sacral wound status until healed, but record review showed no such weekly documentation in the nursing progress notes, and the ADON confirmed that, despite staff training, the nurses had not documented according to policy.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.